Frequently Asked Questions: Obtaining Reimbursement for Stuttering Treatment

• Will my health plan cover stuttering treatment?
• Does the health plan require a physician referral before payment for the treatment of stuttering?
• How do I submit a claim?
• What can I do if my claim is denied?
• What action can I take if my appeal is denied?

Will my health plan cover stuttering treatment?

Review your policy for coverage looking for such terms as "speech therapy," "speech-language pathology," "physical therapy and other rehabilitation services," or "other medically necessary services or therapies." A phone call to the health plan can confirm your interpretation of coverage. Document the name of the person with whom you speak as well as dates and times.

Provide the health plan with information about the neurological basis of stuttering. Use the following reference:

Researchers who studied adults with persistent stuttering found that these individuals had anatomical irregularities in the areas of the brain that control language and speech. Neurology (July 24, 2001).

When speaking with the health plan representative, it may be helpful to provide the diagnosis [PDF] and procedure codes for stuttering: 92521 for speech fluency evaluation, 92507 for individual speech treatment, and 92508 for group speech treatment.

Be sure to record the name of the health plan representative with whom you talked and ask for confirmation of coverage in writing. Specifics of coverage (e.g., any limit on the number of sessions, co-payments, deductible amounts) should also be provided in writing. The health plan should provide this written notification within 30 to 60 days.

Keep copies of all correspondence and detailed records of all verbal communication.

Does the health plan require a physician referral before payment for the treatment of stuttering?

Some insurers do require physician referral or pre-approval. Check your policy booklet.

Health plans may also require information from the speech-language pathologist that includes the diagnostic and treatment codes for stuttering, projected treatment dates or number of treatment sessions anticipated, as well as associated fees.

How do I submit a claim?

Speech treatment for stuttering is usually conducted in one of two ways: weekly sessions or intensive, short-term treatment programs.

A. Weekly Sessions

If speech treatment is provided once or twice a week, claims can be submitted at the completion of each session, after a block of sessions, or filed with a projected number of sessions. If more sessions are needed than originally anticipated, a progress report is submitted to the health plan with a request for coverage for additional sessions. The speech-language pathologist can assist you in determining the best way to submit your claim, or may submit the claim for you.

B. Intensive Short-Term Treatment

If treatment is provided through an intensive short-term treatment program, the claim must be submitted at the completion of the program. Intensive short-term treatment programs are typically conducted over a 2–4 week period.

Once the treatment program is completed, the speech-language pathologist will supply the appropriate diagnosis [PDF] and procedure codes and either you or the clinician will submit this information, along with your insurance form, to the health plan.

What can I do if my claim is denied?

If your claim is denied, request the reasons for denial in writing. You have the right to appeal the denial. Remember, persistence often pays off.

• First, write a letter stating your intention to appeal the denial. The health plan may request additional information about the treatment and/or they may ask for an objective measurement of progress. They may cite as a reason for denial that treatment is "educational in nature" or that treatment is not "medically necessary." Your appeal must address the specific reasons for denial.
• An appeal letter typically includes a description of the disorder and its medical nature. A copy of the physician's referral letter (if needed) should be included. It may be helpful to quote those sections of the policy booklet that describe the coverage for speech-language pathology treatment, if it helps your case. Then you will need to describe how the treatment meets the policy criteria.
• Your speech-language pathologist may help you with this appeal. The American Speech-Hearing-Language Association (ASHA) has developed a letter that you can submit with your appeal letter supporting the stuttering treatment [PDF].

What action can I take if my appeal is denied?

If you feel that your appeal has been unfairly denied, you might:

• Contact your state insurance commissioner to determine if there are any other instances in which claims have been unfairly denied and/or file a complaint. Contact information for your insurance commissioner can be found at the National Association of Insurance Commissioners (NAIC).
• Contact the American Speech-Language-Hearing Association at reimbursement@asha.org.
• Contact the Stuttering Foundation of America by phone (1-800-992-9392) or on their website.
• Recommend to your employer or union that coverage for speech-language treatment should be included in your health benefits plan.
• Consider filing a claim in small claims court or state court if all other efforts fail.

Reference this material as follows: American Speech-Language-Hearing Association Special Interest Division 4, Fluency and Fluency Disorders and Stuttering Foundation of America (1998; Revised 2002). Obtaining reimbursement for stuttering treatment. Rockville MD: Author.